Guest Editorial: Nurses' requirements for information technology: a
challenge for educators
Carol S Bond. RN, MBCS CITP, BA(Hons) MSc EdD
Senior Lecturer, Health Informatics
Bournemouth University, Institute of Health and Community Studies.
Rm B103, Bournemouth House, 19 Christchurch Rd, Bournemouth, BH1
3LH
Tel 01202 967356
Email cbond@bournemouth.ac.uk
Guest Editorial: Nurses' requirements for information technology: a
challenge for educators
Keywords: Nursing Informatics; Internet; nurse education
Introduction
Computers are rapidly becoming an everyday tool for nurses. Many countries are
driving initiatives forward on a national basis, for example in the UK the National
Programme for IT (NPfIT) is developing systems that include nationally available
lectronic health records, networked services to support appointment systems (chose
and book) electronic handling of a wide range of diagnostic tests and results (DoH
2001). Access to information to support practice is also provided through the
Electronic Library for Health. New Zealand has approached the situation differently
(WAVE 2001) considering the need for local customisation of the systems to be an
important feature of their strategy. New Zealand also places information for clinicians
and patients as a high priority.
As the role of the nurse develops, and they take responsibility for new areas of work
their use of computer systems has the potential to increase further. Research carried
out by Courtenay et al (2006) identified that an inability to computer generate
prescriptions was one factor that stopped nurses developing their prescribing role.
Patients are also driving the agenda forward without any need for government policy,
as can be seen from recent, and forthcoming, editions of International Journal of
Nursing Studies. As Alexander & Zeibland (2006) discuss patients are increasingly
using the internet to find information elating to their own particular needs. They
identify the key role that nurses are able to play in supporting patient in meeting
their information needs effectively, and state that their education must prepare them
for this new information role. Gilmore (2006) concludes that increasing equality of
access for patients from diverse backgrounds is reliant on nurses’ expertise in not
only accessing but also evaluating online health information.
The power of the internet is raised by Hitosugi et al (2007) who explain that there is
a high suicide level in their native Japan, where an emerging phenomena is that of
suicide pacts organized through the internet. Whilst Japan is seeking to manage this
through voluntary intervention by internet providers nurses, especially those working
with vulnerable people, should be aware of this type of social development.
The value of the internet isn’t limited to patient information. Yu and Yang (2006)
discuss the value of web based learning for nurses, finding that nurses who work at
village health centers, remote from education bases, valued the access that the
internet afforded them. They also however identified that some nurses lacked the
necessary computer skills to complete online courses. Im et al (2006) explore the
use of the internet as a research tool in their paper discussing the use of an internet
survey with cancer patients.
In order for nurses to be able to work with these computer-based systems, and to be
able to support their patients’ effectively they need. at the very least to have the
skills and knowledge to use information technology (IT) efficiently and safely. Nurses
however have been found to have poor IT skills (Bond 2004, Griffiths & Riddington
2001) and are resistant to the introduction of IT (Timmons, 2003). Kirshbaum
(2004) found that nurses more frequently reported being wary of using computers
than other healthcare staff groups and made more negative statements e.g. ‘I avoid
using computers whenever I can’ and ‘I feel uncomfortable about the thought of
using computers’.
In the UK a National Audit Office report into the implementation NPfIT (NAO 2006)
considered that a lack of IT skills within the National Health Service (NHS) was a risk
to the timely implementation of the programme.
Just what skills are needed is not universally agreed. The NHS (NHSIA 2001) has
published competencies required of nurses, which includes a range of knowledge and
skills falling under the remit of nursing informatics, including clinical informatics,
information governance and information security, as well as basic IT skills. In spite of
this the perception found in some studies (Murphy et al 2002, Murphy et al 2004), is
that all nurses need are basic IT skills.
One of the aims of Information for Health (NHS Executive 1998) was to establish,
amongst other things, a culture to ensure that NHS clinicians would be able to access
the information that they need to provide effective patient care. In the case of nurses
the evidence suggests that this culture is not yet established. I have recently
completed two major pieces of work, that sought to explore why this is, and what it
is that nurses want in order to engage with IT in their work.
One was undertaken in the UK, a doctoral thesis, (Bond 2006a) which looked at how
student nurses develop informatics skills and knowledge. The final phase of data
collection included questionnaires to 132 final year students asking about their
experience of using computers in practice. Group interviews were also held with 15
qualified staff who support students in practice to explore their attitudes to, and use
of computers.
The second, supported by a Florence Nightingale Foundation Travel Scholarship
(Bond 2006b), was undertaken in New Zealand where a 5 week visit enabled me to
talk to a nurses from a range of disciplines, mainly in acute hospitals, about their
requirements both in what a computer system should provide, and what support they
considered essential.
Nurses generally mentioned using a combination of computerised patient record
systems and care planning systems. Fewer staff mentioned using computers to
access evidence based information, or information for their patients.
What Nurses Want
Generally nurses said that they wanted computer systems to make their lives easier.
This includes saving time by automating tasks such as stock ordering. One essential
element to meet this need is that systems need to talk to each other so that
information from all points of care is automatically shared through the system, and
data entry minimised.
Offering good quality decision support and access to evidence based information was
not a high a priority for many nurses, although it was considered a higher priority by
those with nursing informatics expertise. Those who did want it, want it to be
available when and where they need it, and for it to regularly updated.
A very important requirement was that computers need to be available wherever the
nurse and patient are. Wireless networks and portable computers were suggested as
the best way of meeting this need. Computers at workstations were not popular for
several reasons, including the pressure to find a free computer at the end of shift to
update records. Point of care data entry was not only seen as meeting nurses’
requirements but also as having the potential contribute to improved patient care by
allowing records to be updated contemporaneously when memories are fresh, a great
improvement on handwritten notes being scribbled and kept until the nurse can get
back to a free computer.
Passwords are a big problem for many nurses. Each individual system often requires
its own login information, each renewable on a different cycle. Nurses were almost
unanimous in wanting this simplified. The ideal solution was seen as each nurse
having just one initial login giving entry to all subsequent systems.
Support was a frequently mentioned need. Nurses want help available that fits with
their work patterns (e.g. on the ward) and that addresses immediate problems when
they arise. Although training on systems was seen as important the need for ongoing
support was also identified. Most nurses did not want this through manuals or
computer aided learning programmes that they had to use in their own time. Those
with poor skills, or a lack of confidence in their skills, were not comfortable with the
idea of using a computer programme to learn how to use a computer. Nor was the
ability to contact a helpdesk seen as meeting their needs, especially ones’ that used
voicemail as nurses were often not able to take a call-back, especially if it was some
time after the initial query. The most popular support method mentioned was for a
specialist nurse to be available to come and give one to one help when and where
problems were encountered. A nurse was requested rather than an IT person
because there was a feeling that a nurse would understand the context of the
situation, what the nurse with the problem was trying to do and how they needed to
do it. Nurses, especially but not only those who lacked confidence, did not feel that
IT specialists ‘talked their language’ or saw their problems in the same way that they
did.
The four biggest barriers to the use of computers that were identified were:

The co-existence of paper based systems, meaning that nurses didn’t have to
engage with the computerised systems. This was seen as leading to
computerised systems being incomplete and therefore promoting the use of
paper-based systems.

Systems being slow and not user friendly so that using the computer took
longer than doing the same task did (or had done) in a paper-based system.
Linked with this was a distrust of computers with the fear that they would
increase workload by making tasks that were previously done by
administrative staff part of the nurse’s workload.

Lack of support when and where it was needed. Nurses did not see waiting for
help as being acceptable when a problem was stopping them doing work that
they needed to do.

Computers not being available where and when they were needed. A culture
of using computers not being seen as being as important as giving patient
case was often mentioned. Nurses keen to engage would like to have
computers available at the bedside (or consultation room) so that they
become part of care giving rather than part of a separate administrative
workload.
Nurses tended to focus more on using systems than they did on accessing
information to support care. Often there was a lack of awareness of what was
available which would partly explain this, however it is also likely to be
attributable to a culture where spending time on a computer is not seen as being
as valuable an activity as spending time with a patient, irrespective of what is
actually being done in either case.
Student nurses had two priorities. One was developing the skills and knowledge
they needed to be able to understand and use the available equipment and
programmes effectively.. In New Zealand I found that nursing informatics was
embedded in pre-registration nursing curricula, basic IT skills however were not.
Students who had poor skills, or low levels of confidence in their skills, wanted
basic skills to be included as well. In England nursing informatics is not as well
embedded, although programmes may include some basic IT skills. Nursing
informatics expertise has been found to be lacking in UK course teams (Brittain &
Norris 2000, Murphy et al 2004).
The second priority of students was to be encouraged to use computers in
practice. Many students in my doctoral study (Bond 2006a) reported that their
mentors and other qualified staff that they worked with in practice settings had
negative attitudes towards computers, poor skills and knowledge about what
could be done with the computers available, and offered little support or
encouragement to the student.
Two studies undertaken on behalf of the NHS Information Authority (NHSIA
2004) found that informatics needed to be more fully integrated into both preand
post registration education. Both education and practice were seen as having
a negative view of the relevance of informatics and IT within pre-registration
programmes.
Three main types of nurses emerged from the information collected.
The Engagers. Nurses who used computers quite extensively. As well
as using the systems that they were required to use they also mentioned
using computers to access research and library resources to support
evidenced based care. One nurse commented that she wouldn’t want to see
nursing without good computer systems to support it. This group were more
willing to tolerate imperfect systems and to see ways that they could be
improved.
The Worried Willing. Nurses who would be willing to use
computers, but felt that they lacked the skills to use systems confidently.
One nurse was finding that patients and families were using the Internet for
information and felt that they expected her to be competent as well. She
considered that education programmes should be including this so that newly
qualified nurses had these skills from the outset, and that courses should be
available for qualified staff to catch up. This group struggled with imperfect
systems and wanted access to help and support.
The Resisters. Nurses who did not want to use computers. The
comments from nurses in this group included that paperwork was easier
before computers, and that with new computerised systems nurses were
having to do work that ward clerks did previously. These nurses tended to see
computers as taking nurses away from patient care. This group felt that poor
systems justified their not using them.
Conclusions
Nurses do not only need to be able to use IT systems, they need to be able to work
effectively with both information and technology. Nurses who are comfortable
working with computers appear to be much more tolerant of failures in the systems
and most importantly want to develop systems that meet their needs. The ‘willing
worried’ nurses who feel that they lack skills but are willing to engage need support
to do so that meets their needs. If this is achieved there is no reason to suppose that
they will not develop into engagers.
Whatever the resisters may wish, computers are not going to disappear from
healthcare, rather their use is going to increase. Changing the views of these nurses
is a challenge for staff development. It is one that needs to be met however not only
so that they can meet the needs of their patients, but also because these nurses can
be the ones supporting students, or who provide the role models for students in
practice.
Rather than taking nurses away from patients computers are becoming part of care
giving. Nurses therefore cannot be allowed to start their careers as either the worried
willing or as resisters. All newly qualified nurses should have the skills and
knowledge to use information and technology effectively. The leaders in nurse
education need to ensure that this is achieved.
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